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  <form class="jotform-form" action="http://submit.jotformz.com/submit/23337306045649/" method="post" name="form_23337306045649" id="23337306045649" accept-charset="utf-8">
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        <ul class="form-section">
        <li class="form-line" id="id_5">
        <label class="form-label-top" id="label_5" for="input_5">
          1- Como você classificaria sua saúde em Geral ?<span class="form-required">*</span>
        </label>
        <div id="cid_5" class="form-input-wide">
          <div class="form-single-column"><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_5_0" name="q5_1Como5" value="Excelente" />
              <label for="input_5_0"> Excelente </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_5_1" name="q5_1Como5" value="Muito boa" />
              <label for="input_5_1"> Muito boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_5_2" name="q5_1Como5" value="Boa" />
              <label for="input_5_2"> Boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_5_3" name="q5_1Como5" value="Razoável" />
              <label for="input_5_3"> Razoável </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_5_4" name="q5_1Como5" value="Ruim" />
              <label for="input_5_4"> Ruim </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_6">
        <label class="form-label-top" id="label_6" for="input_6">
          2- Como você classifica a saúde da boca?<span class="form-required">*</span>
        </label>
        <div id="cid_6" class="form-input-wide">
          <div class="form-single-column"><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_6_0" name="q6_2Como6" value="Excelente" />
              <label for="input_6_0"> Excelente </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_6_1" name="q6_2Como6" value="Muito boa" />
              <label for="input_6_1"> Muito boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_6_2" name="q6_2Como6" value="Boa" />
              <label for="input_6_2"> Boa </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_6_3" name="q6_2Como6" value="Razoável" />
              <label for="input_6_3"> Razoável </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_6_4" name="q6_2Como6" value="Ruim" />
              <label for="input_6_4"> Ruim </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      <li class="form-line" id="id_7">
        <label class="form-label-top" id="label_7" for="input_7">
          3- Você sentiu dor na face, em locais como região das bochechas ( maxilares) nos lados da cabeça, na frente do ouvido ou no ouvido, nas ultimas 4 semanas?<span class="form-required">*</span>
        </label>
        <div id="cid_7" class="form-input-wide">
          <div class="form-single-column"><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_7_0" name="q7_3Voce7" value="Sim" />
              <label for="input_7_0"> Sim </label></span><span class="clearfix"></span><span class="form-radio-item" style="clear:left;"><input type="radio" class="form-radio validate[required]" id="input_7_1" name="q7_3Voce7" value="Não" />
              <label for="input_7_1"> Não </label></span><span class="clearfix"></span>
          </div>
        </div>
      </li>
      
      <li id="cid_55" class="form-input-wide">
        <div class="form-pagebreak">
          <div class="form-pagebreak-back-container form-label-left">
            <button type="button" class="form-pagebreak-back  form-submit-button-book_blue1" id="form-pagebreak-back_55">
            </button>
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              Próximo
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        </div>
      </li>
      </ul>
      </div>
  </form>
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